Every finding on record at Frontier Medical Home Care, Inc.

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of New Mexico Health Care Authority (HCA). An unannounced on-site Recertification survey at the above-named Home Health Agency (HHA) from 05/06/25-05/08/25 resulted in the finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Mexico Health Care Authority (HCA). An unannounced on-site Recertification survey conducted at the above-named Home Health Agency (HHA) facility from 05/06/25-05/08/25 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review, interviews, and policy review, the home health agency (HHA) failed to reconcile medications and update the medication profile for one patient observed, for one of three patients (Patient (P) 1) during three home visits completed on 05/06/25 to 05/07/25. This deficient practice had the potential to affect the current 96 patients, and any future patient admitted to the HHA in need of services. Findings include: Review of the undated agency's policy titled, "Medication Monitoring" revealed, "The Monitoring Process includes at least the following elements…Reviewing and evaluating the medication profile…The findings, conclusions and recommendations of medication monitoring are communicated to the physician. The findings, conclusions and recommendations of medication monitoring are documented in the patient’s medical record." Review of P1’s 485 plan of care (POC) located under the "Orders" tab of the electronic medical record (EMR) and provided by the facility, for the certification periods of 02/28/25 to 04/28/25 and 04/29/25 to 06/27/25, indicated that P1 began services with the HHA on 02/28/25 and Physical Therapy (PT) services were to be provided two times per week. Review of P1’s "Patient Medication Record (medication profile)" located under the "Orders" tab of the EMR for these certification periods revealed that P1 was taking a total of nineteen medications including Tamsulosin HCL 0.4 milligrams (mg) every day as a genitourinary agent. During the home visit observation in P1’s home and interview on 05/06/25 beginning at approximately 4:20 PM, Physical Therapist Assistant (PTA) 1 began assisting P1 with exercises. Near the end of the visit at approximately 5:10 PM when the Surveyor noticed no mention of PTA1 reviewing medications P1 was currently taking, the Surveyor reviewed the list of medications on the medication profile the HHA had provided for the home visit with P1 and P1 provided a list of the current medications that were on a piece of lined paper from P1’s wallet to compare with the profile provided by the HHA. There was no Tamsulosin on the list provided by P1 who stated, "Oh I quit taking that about a month ago." P1 had mentioned earlier in the visit that he/she was no longer urinating and was having hemodialysis treatments three times per week. P1 stated the HHA folder was misplaced in P1’s home and thus could not be reviewed for a medication list. During a daily debriefing interview on 05/07/25 at 3:00 PM, the Director of Nursing (DON) reported that the HHA no longer provided a medication list (medication profile) in any of the agency’s patients’ home folders since patients had "misplaced them too often." The DON indicated that if patients' weeks were therapy only cases (Physical Therapy, Occupational Therapy, or Speech Therapy), such as that of P1, the therapists were to ensure that medications were current and updated in the patients’ medical record. During a telephone interview with PTA1 on 05/08/25 at 11:47 AM, PTA1 stated, "I’ll be honest. I don’t ask about medications at every visit, but I generally ask about every two weeks."

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review, interviews, and policy review, the home health agency (HHA) failed to ensure services were provided that were ordered by the physician as indicated in the patient’s plan of care (POC) for one (Patient (P) 4) of seven sampled patient records reviewed. This deficient practice had the potential to affect the current 96 patients, and any future patient admitted to the HHA for services. Findings include: Review of the undated agency's policy titled "Medical Policies" indicated "…The attending physician certifies the need for [name of HHA] services and establishes a Plan of Treatment… which includes: Frequency of visits…Treatment and drugs can be administered only as ordered by the physician." Review of P4’s POC located under the "Orders" tab of the electronic medical record (EMR) for the certification period of 04/16/25 to 06/14/25 indicated that Occupational Therapy (OT) services were to be provided three times per week for eight weeks. Review of OT visits located under the "OT therapy" tab of the EMR, revealed that two OT visits were made for week one beginning on 04/16/25; one OT visit was made and there was one missed OT visit for week two beginning on 04/19/25; two OT visits were made in week three beginning on 04/26/25. During an interview on 05/08/25 at 8:51 AM with the Director of Nursing (DON), the POC and OT visits for this certification period were reviewed. The DON indicated that the orders for the frequency of OT visits on the POC were "A mistake. It [the POC frequency of OT orders] should have been two times a week not three. I forgot that insurance won’t let us order frequencies of one to two or three times per week and make us order specific frequency." The DON confirmed that the OT visits were not conducted three times per week as ordered by the physician on the POC.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review, interview, and policy review, the home health agency (HHA) failed to ensure communication related to the patient’s plan of care (POC) with the physician was documented in the patient’s electronic medical record (EMR) for one (Patient (P) 4) of seven patient records reviewed. This deficient practice had the potential to affect the current 96 patients, and any further patient admitted to the HHA in need of services. Findings include: Review of the undated agency's policy titled, "Coordination of Services" indicated "…staff promptly contacts the physician…When there are changes in the patient’s condition…When changes occur in caregiver support…" Review of the undated agency's policy titled, "Assessment" indicated "…Missed visit reports will be completed for any visits not made…" Review of P4’s EMR under the "Occupational Therapy (OT)" tab for the certification period of 04/16/25 to 06/14/25, revealed that on 04/25/25 there was a missed OT visit. Review of the physician "Orders" tab of the EMR revealed no missed visit report was documented, and no missed visit notification was made to P4’s physician of the missed visit. During an interview on 05/08/25 at 1:45 PM the Director of Nursing (DON) confirmed that a missed visit report should have been documented for the missed OT visit on 04/25/25 and that the report should have been sent to the physician, but it was not done.

E0000 A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Mexico Department of Health. An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 05/02/22 to 05/04/22 resulted in a finding of standard level deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: E0009 Based on policy review and interview, the home health agency (HHA) failed to develop a process for ensuring cooperation and collaboration with tribal, regional, State, and Federal emergency preparedness officials' efforts to ensure an integrated response during a disaster or emergency situation. This deficient practice had the potential to affect the current 67 HHA patients and any future patient admitted for services by the agency. Findings include: Review of the "Emergency Management Plan" included in the policy manual presented by Director of Nursing (DON) and reviewed on 12/07/21, indicated no process had been developed to ensure cooperation and collaboration by the HHA with tribal, regional, State, and Federal emergency preparedness officials' efforts to ensure an integrated response occurred during a disaster or emergency situation. In an interview on 05/04/22 at 9:15 AM, DON confirmed the agency's emergency preparedness plan did not include a process for cooperating and collaborating with tribal, regional, State, and Federal emergency preparedness officials.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: E0031 Based on policy review and interview, the home health agency (HHA) failed to ensure the communication plan included contact information for the tribal, regional, State, and Federal emergency preparedness officials. This deficient practice had the potential to affect the current 67 HHA patients and any future patient admitted for services by the agency. Findings include: Review of the "Emergency Management Plan" included in the policy manual presented by Director of Nursing (DON) and reviewed on 12/07/21, indicated the agency's communication plan did not include contact information for the tribal, regional, State, and Federal emergency preparedness officials. In an interview on 05/04/22 at 9:15 AM, DON confirmed the agency's emergency preparedness communication plan did not include contact information for the tribal, regional, State, and Federal emergency preparedness officials.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: E0033 Based on policy review and interview, the home health agency (HHA) failed to ensure the communication plan included a method for sharing information and medical documentation for patients under the agency's care with other health providers to maintain the continuity of care and a means of providing information about the general condition and location of patients under the HHA's care. This deficient practice had the potential to affect the current 67 HHA patients and any future patient admitted for services by the agency. Findings include: Review of the HHA's "Emergency Management Plan" dated 12/07/21, included in the policy manual presented by Director of Nursing (DON), indicated the agency's communication plan did not include the method for sharing information and medical documentation for patients under the agency's care with other health providers to maintain the continuity of care and a means of providing information about the general condition and location of patients under their care. In an interview on 05/04/22 at 9:15 AM, DON confirmed the agency's emergency preparedness communication plan did not include the method for sharing information and medical documentation for patients under the agency's care with other health providers to maintain the continuity of care and a means of providing information about the general condition and location of patients under their care.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: E0034 Based on policy review and interview, the home health agency (HHA) failed to ensure the communication plan included the means of providing information about the HHA's occupancy, needs, and its ability to assist the authority having jurisdiction. This deficient practice had the potential to affect the current 67 HHA patients and any future patient admitted for services by the agency. Findings include: Review of the HHA's "Emergency Management Plan" dated 12/07/21, included in the policy manual presented by Director of Nursing (DON), indicated the agency's communication plan did not include the means of providing information about the HHA's occupancy, needs, and its ability to assist the authority having jurisdiction. In an interview on 05/04/22 at 9:15 AM, DON confirmed the agency's emergency preparedness communication plan did not include the means of providing information about the HHA's occupancy, needs, and its ability to assist the authority having jurisdiction.

G0000 A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Mexico Department of Health. An unannounced on-site Recertification Survey conducted at the above-named Home Health Agency (HHA) facility from 05/02/22 to 05/04/22 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below. The HHA census was 67.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: G616 Based on record review, policy review, observations, and interviews, the home health agency (HHA) staff failed to observe the medications the patient is taking in the home, reconcile the medication list in the medical record, and update the medication list in the home for two patients (Patient (P)2, P4) observed during three home visit completed on 05/03/22. This deficient practice had the potential to affect the current 67 patients and any future patient admitted to the HHA for services. Findings include: Review of the undated agency policy titled "Medication Monitoring," indicated ". . . The skilled nurse/therapist monitors the patient's response to medications at least once a week if needed and more frequently if needed, based on the patient's clinical needs and/or response to care, treatment and/or services. The monitoring process includes at least the following elements: . . . Reviewing and evaluating the medication profile . . . The findings, conclusions and recommendations of medication monitoring are communicated to the physician. The findings, conclusions and recommendations of medication monitoring are documented in the patient's medical record." 1. Review of P2's "Patient Medication Record" (medication profile) for the certification period of 04/02/22 to 05/31/22 revealed two medications were listed, Vitamin D (responsible for increasing drug absorption of calcium, magnesium, and phosphate, and many other biological effects) and Clopidogrel (used to prevent heart attacks and strokes in persons with heart disease, recent stroke, or blood circulation disease). Observation during a home visit with P2 on 05/03/22 at 9:50 AM revealed six additional medications provided by P2's caregiver who stated P2 was currently taking the medications. The six medications were not listed on P2's medication profile. The medications included Aspirin EC (used to reduce fever and relieve mild to moderate pain) 81 milligrams (mg), one orally daily; Amlodipine Besylate (used with or without other medications to treat high blood pressure)10 mg, one orally daily; Ezetimibe (used along with a low cholesterol/low fat diet and exercise to help lower cholesterol in the blood) 10 mg, one orally daily; Atorvastatin (used along with a proper diet to help lower "bad" cholesterol and fats and raise "good" cholesterol in the blood) 40 mg, one orally daily; Carvedilol (used to treat high blood pressure and heart failure) 0.625 mg, one orally twice a day; Folic Acid 1 mg, one orally daily. P2 was receiving therapy and aide services only, and nursing was not being provided during this current certification period. In an interview on 05/03/22 at 9:50 AM during the home visit, Certified Occupational Therapist Assistant (COTA) 1 stated if P2 had a medical appointment since COTA1's last visit, COTA1 would ask P2 if any new medications were prescribed, and COTA1 would provide education about the drug. COTA1 stated COTA1 does not check the medications against the medication profile during the visit. In an interview on 05/04/22 at 8:30 AM, Director of Nursing (DON) stated it had never been brought to DON's attention before that the therapist was to reconcile the medications against the profile. DON stated he/she didn't interpret the medication policy meaning the therapist had to review the medications. 2. Review of P4's "Patient Medication Record" for the certification period of 04/12/22 to 06/10/22 indicated five medications listed on the record were not presented by P4 when a request was made to view P4's medications during a home visit on 05/03/22 at 10:45 AM. The medications included Omeprazole (used to treat certain stomach and esophagus problems) oral 20 mg one capsule every day; Celecoxib (nonsteroidal anti-inflammatory drug which relieves pain and swelling) 100 mg one capsule orally twice a day; Cetirizine HCL (antihistamine used to relieve allergy symptoms) 10 mg one tablet orally every day; Dicyclomine HCL (used to treat a certain type of intestinal problem called irritable bowel syndrome) 20 mg tablet orally twice a day as needed for ulcer. Further observation revealed a bottle of Aller-Zyr (temporarily relieves symptoms due to hay fever or other upper respiratory allergies) over-the-counter was presented by P4 and was not listed on the medication profile. In an interview on 05/03/22 at 10:45 AM, Physical therapist (PT) 1 stated he/she asks the patient if there are any new medications since the last visit, but PT1 does not check the medications against the medication profile. PT1 stated "the nurse does that." In an interview on 05/04/22 at 8:30 AM, Director of Nursing (DON) stated it had never been brought to DON's attention before that the therapist was to review the medications against the profile. DON stated he/she didn't interpret the medication policy meaning the therapist had to review the medications.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: G687 Based on policy review and interview, the home health agency (HHA) failed to ensure its COVID-19 vaccination policy included the process required by the Center for Medicare & Medicaid Services (CMS) federal regulation as identified in Center for Clinical Standards and Quality/Quality, Safety & Oversight Group QSO-22-07 revised 04/05/22. This deficient practice had the potential to cause serious injury or harm to the current staff, the current 67 patients, and any future staff hired, and any future patient admitted to the agency for services. Findings include: Review of the undated agency policy titled "Exposure Control Plan" indicated ". . .The vaccination program consists of a series of one to two vaccinations with possible boosters. Personnel receive information regarding vaccination, including its safety and effectiveness. . ." Review of the above policy indicated the policy did not address the process for reviewing and documenting staff COVID-19 vaccinations, the process for staff to request exemptions, the process for tracking and securely documenting the vaccination status and approved exemptions of staff, the process for ensuring that all documentation that confirms and supports the medical exemption from vaccination exists, and the process for the tracking and secure documentation of the vaccination status of staff for whom vaccination must be temporarily delayed. In an interview on 05/03/22 at 2:25 PM, Director of Nursing (DON) confirmed the agency's vaccination policy does not include all the required components/processes required by the regulation.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: G710 Based on record review, policy review, and interviews, the home health agency (HHA) failed to ensure services were provided that were ordered by the physician as indicated in the patient's plan of care (POC) for five (Patient (P) 2, P6, P8, P9, P10) of 10 sampled patient records reviewed. This deficient practice had the potential to affect the current 67 patients and any future patient admitted to the HHA for services. Findings include: Review of the undated agency policy titled "Medical Policies" indicated ". . . The attending physician certifies the need for [name of HHA] services and establishes a Plan of Treatment. . . which includes: All pertinent diagnosis Type of services: e.g., [that is] patient needs, nursing care, aide, physical therapy Frequency of visits, amount, and duration . . . Treatment and drugs can be administered only as ordered by the physician. . ." 1. Review of P2's "Home Health Certification and Plan of Care," located under the "Orders" tab in the electronic medical record (EMR), for the certification period of 02/01/22 to 04/01/22 indicated the occupational therapy (OT) frequency and speech therapy (ST) frequency were each one to three times a week for four to eight weeks. Review of P2's "Missed Visit Form (COTA [certified occupational therapy assistant] Visit)," located under the OT" tab in the EMR, dated 03/22/22, and documented by COTA1, indicated ". . .Pt [patient] out of town for Dr [doctor] appt [appointment] . . . MD [medical doctor] Notified: No . . ." Review of P2's "Missed Visit Form (COTA Visit)," dated 03/24/22 and documented by COTA1, indicated ". . . No Answer to Phone Call. . . MD Notified: No . . ." There was no documentation that an OT visit was made the week of 03/19/22 in accordance with P2's POC. Review of P2's "Missed Visit Form (ST Visit)," located under the "ST" tab in the EMR, dated 03/07/22, and documented by SLP (speech language pathologist) 1, indicated ". . . SLP not available to provide therapy this date. . . MD Notified: No . . ." Review of P2's "Missed Visit Form (ST Visit), dated 03/09/22 and documented by SLP1, indicated ". . . SLP remains unavailable for therapy. . . MD Notified: No . . ." There was no ST visit made the week of 03/05/22 in accordance with P2's POC. In an interview on 05/03/22 at 2:25 PM, Director of Nursing (DON) stated P2's physician should have been notified of the missed OT visit the week of 03/19/22 and the missed ST visit the week of 03/05/22. 2. Review of P6's "Home Health Certification and Plan of Care," located under the "Orders" tab in the EMR, for the certification period of 01/29/22 to 03/29/22 indicated the ST frequency was one to three times a week for four to eight weeks. Review of P6's "Missed Visit Form (ST Visit)," located under the "ST" tab in the EMR, dated 03/07/22, and documented by SLP1, indicated ". . . SLP not available to provide therapy this date. . . MD Notified: No . . ." Review of P6's "Missed Visit Form (ST Visit), dated 03/09/22 and documented by SLP1, indicated ". . . SLP remains unavailable for therapy. . . MD Notified: No . . ." There was no ST visit was made the week of 03/05/22 in accordance with P6's POC. In an interview on 05/03/22 at 2:25 PM, DON stated there was no ST visit made the week of 03/05/22, and P6's physician should have been notified. 3. Review of P8's "Home Health Certification and Plan of Care," located under the "Orders" tab in the EMR, for the certification period of 12/24/21 to 02/21/22 indicated the skilled nurse (SN) frequency ordered was one to three times a week for four weeks. Review of P8's "Missed Visit Form (RN [registered nurse] – Skilled Nursing Visit), located under the "Nursing" tab in the EMR, dated 12/30/21, and documented by RN2, indicated ". . . No Answer to Phone Call . . . Unable to reach pt. [patient]. . . MD Notified: No . . ." There was SN visit made the week of 12/25/21 in accordance with P8's POC. In an interview on 05/03/22 at 2:25 PM, DON confirmed there was no SN visit made the week of 12/25/21, and P8's physician should have been notified. 4. Review of P9's "Home Health Certification and Plan of Care," located under the "Orders" tab in the EMR, for the certification period of 01/03/22 to 03/03/22 indicated the PT frequency ordered was one to three times a week for four to eight weeks. Review of P9's "Missed Visit Form (PTA [physical therapy assistant] Visit), located under the "PT" tab in the EMR, dated 01/18/22 and 01/20/22 (two separate missed visit notes), documented by PTA1, indicated ". . . PTA out sick . . . MD Notified: No . . ." There was no PT visit made the week of 01/15/22 in accordance with P9's POC. In an interview on 05/03/22 at 2:25 PM, DON confirmed there was no PT visit made the week of 01/15/22, and P9's physician should have been notified. 5. Review of P10's "Home Health Certification and Plan of Care," located under the "Orders" tab in the EMR, for the certification period of 02/28/22 to 04/28/22 indicated the PT frequency ordered was one to three times a week for three to nine weeks. Review of P10's "Missed Visit Form (PTA Visit), located under the "PT" tab in the EME, dated 04/11/22, and documented by PTA1, indicated ". . . Patient requested that therapy be withheld 04/11 [04/11/22] thur [sic] 04/15/22 this week due to easter holiday. . . MD Notified: NO . . ." There was no PT visit made the week of 04/09/22 in accordance with P10's POC. In an interview on 05/03/22 at 2:25 PM, DON confirmed that no PT visits were made the week of 04/09/22, and P10's physician should have been notified.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: G718 Based on record review, policy review, and interviews, the home health agency (HHA) failed to ensure communication related to the patient's plan of care (POC) with all physicians involved was documented in the patient's electronic medical record (EMR) for five (Patient (P) 2, P6, P8, P9, P10) of 10 sampled patient records reviewed. This deficient practice had the potential to affect the current 67 patients and any future patient admitted to the HHA for services. Findings include: Review of the undated policy titled "Coordination of Services" indicated ". . . staff promptly contacts the physician" When there are changes in the patient's condition With results of relevant laboratory tests When there are changes in the patient's expected response to treatment and/or medications When changes occur in caregiver support or the environment When [name of HHA] can no longer adequately meet the patient's medical, nursing, and/or social needs in the patient's place of residence. . ." There was no documentation in the policy that addressed the need for staff to communicate with the patient's information related to changes in the patient's plan of care. Review of the undated policy titled "Assessment" indicated ". . . Missed visit reports will be completed for any visits not made. . ." There was no documentation in the policy that addressed that staff needed to report missed visits that caused a change to the patient's POC. 1. Review of P2's "Home Health Certification and Plan of Care," located under the "Orders" tab in the electronic medical record (EMR), for the certification period of 02/01/22 to 04/01/22 indicated the occupational therapy (OT) frequency and speech therapy (ST) frequency were each one to three times a week for four to eight weeks. Review of P2's "Missed Visit Form (COTA [certified occupational therapy assistant] Visit)," located under the OT" tab in the EMR, dated 03/22/22, and documented by COTA1, indicated ". . .Pt [patient] out of town for Dr [doctor] appt [appointment] . . . MD [medical doctor] Notified: No . . ." Review of P2's "Missed Visit Form (COTA Visit)," dated 03/24/22 and documented by COTA1, indicated ". . . No Answer to Phone Call. . . MD Notified: No. . ." There was no documentation that an OT visit was made the week of 03/19/22 in accordance with P2's POC, and there was no documentation that P2's physician was notified of the change to P2's POC. Review of P2's "Missed Visit Form (ST Visit)," located under the "ST" tab in the EMR, dated 03/07/22, and documented by SLP (speech language pathologist) 1, indicated ". . . SLP not available to provide therapy this date. . . MD Notified: No . . ." Review of P2's "Missed Visit Form (ST Visit), dated 03/09/22 and documented by SLP1, indicated ". . . SLP remains unavailable for therapy. . . MD Notified: No. . ." There was no ST visit made the week of 03/05/22 in accordance with P2's POC, and there was no documentation that P2's physician was notified of the change to P2's POC. In an interview on 05/03/22 at 2:25 PM, Director of Nursing (DON) stated P2's physician should have been notified of the missed OT visit the week of 03/19/22 and the missed ST visit the week of 03/05/22. 2. Review of P6's "Home Health Certification and Plan of Care," located under the "Orders" tab in the EMR, for the certification period of 01/29/22 to 03/29/22 indicated the ST frequency was one to three times a week for four to eight weeks. Review of P6's "Missed Visit Form (ST Visit)," located under the "ST" tab in the EMR, dated 03/07/22, and documented by SLP1, indicated ". . . SLP not available to provide therapy this date. . . MD Notified: No . . ." Review of P6's "Missed Visit Form (ST Visit), dated 03/09/22 and documented by SLP1, indicated ". . . SLP remains unavailable for therapy. . . MD Notified: No. . ." There was no ST visit was made the week of 03/05/22 in accordance with P6's POC, and there was no documentation that P6's physician was notified of the change to P6's POC. In an interview on 05/03/22 at 2:25 PM, DON stated there was no ST visit made the week of 03/05/22, and P6's physician should have been notified. 3. Review of P8's "Home Health Certification and Plan of Care," located under the "Orders" tab in the EMR, for the certification period of 12/24/21 to 02/21/22 indicated the skilled nurse (SN) frequency ordered was one to three times a week for four weeks. Review of P8's "Missed Visit Form (RN [registered nurse] – Skilled Nursing Visit), located under the "Nursing" tab in the EMR, dated 12/30/21, and documented by RN2, indicated ". . . No Answer to Phone Call . . . Unable to reach pt. [patient]. . . MD Notified: No . . ." There was SN visit made the week of 12/25/21 in accordance with P8's POC, and there was no documentation that P8's physician was notified of the change to P8's POC. In an interview on 05/03/22 at 2:25 PM, DON confirmed there was no SN visit made the week of 12/25/21, and P8's physician should have been notified. 4. Review of P9's "Home Health Certification and Plan of Care," located under the "Orders" tab in the EMR, for the certification period of 01/03/22 to 03/03/22 indicated the PT frequency ordered was one to three times a week for four to eight weeks. Review of P9's "Missed Visit Form (PTA [physical therapy assistant] Visit), located under the "PT" tab in the EMR, dated 01/18/22 and 01/20/22 (two separate missed visit notes), documented by PTA1, indicated ". . . PTA out sick . . . MD Notified: No . . ." There was no PT visit made the week of 01/15/22 in accordance with P9's POC, and there was no documentation that P9's physician was notified of the change to P9's POC. In an interview on 05/03/22 at 2:25 PM, DON confirmed there was no PT visit made the week of 01/15/22, and P9's physician should have been notified. 5. Review of P10's "Home Health Certification and Plan of Care," located under the "Orders" tab in the EMR, for the certification period of 02/28/22 to 04/28/22 indicated the PT frequency ordered was one to three times a week for three to nine weeks. Review of P10's "Missed Visit Form (PTA Visit), located under the "PT" tab in the EME, dated 04/11/22, and documented by PTA1, indicated ". . . Patient requested that therapy be withheld 04/11 [04/11/22] thur [sic] 04/15/22 this week due to easter holiday. . . MD Notified: NO . . ." There was no PT visit made the week of 04/09/22 in accordance with P10's POC, and there was no documentation that P10's physician was notified of the change to P10's POC. In an interview on 05/03/22 at 2:25 PM, DON confirmed that no PT visits were made the week of 04/09/22, and P10's physician should have been notified.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: G954 Based on interview, the home health agency (HHA) failed to have a qualified, pre-designated person authorized in writing by the administrator and the governing body to assume the same responsibilities and obligations as the administrator in the absence of the administrator. This deficient practice had the potential to affect the 29 staff and any future staff hired, the current 67 patients, and any future patient admitted for home health services. Findings include: In an interview on 05/04/22 at 9:45 AM, Administrator stated he/she could not find written authorization from the governing body naming a qualified individual to act as Administrator in the absence of himself/herself.